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Objectives: To assess the accuracy of ultrasound measurement of the lower uterine segment (LUS) thickness against findings at laparotomy, and to investigate its correlation with the success rate of vaginal birth after one previous caesarean delivery (CD) in a resource‐limited setting. Design: Prospective study. Setting: Obstetrics and Gynaecology department in a tertiary hospital in Ghana. Population: Women with one previous CD undergoing either a trial of labour (TOLAC) or elective CD. Methods: Myometrial lower uterine segment thickness (mLUS) and full lower uterine segment thickness (fLUS) were measured with transvaginal ultrasound (TVUS). The women were managed according to local protocols with the clinicians blinded to the ultrasound measurements. The LUS was measured intraoperatively for comparison with ultrasound measurements. Main outcome measures: Lower uterine segment findings at laparotomy, successful vaginal birth. Results: A total of 311 pregnant women with one previous CD were enrolled; 147 women underwent elective CD and 164 women underwent a TOLAC. Of the women that underwent TOLAC, 96 (58.5%) women had a successful vaginal birth. The mLUS was comparable to the intraoperative measurement in the elective CD group with LUS thickness <5 mm (bias of 0.01, 95% CI −0.10 to 0.12 mm) whereas fLUS overestimated LUS <5 mm (bias of 0.93, 95% CI 0.80–1.06 mm). Successful vaginal birth rate correlated with increasing mLUS values (odds ratio 1.30, 95% CI 1.03–1.64). Twelve cases of uterine defect were recorded. LUS measurement ≤2.0 mm was associated with an increased risk of uterine defects with a sensitivity of 91.7% (95% CI 61.5–99.8%) and specificity of 81.8% (95% CI 75.8–86.8%). Conclusion: Accurate TVUS measurement of the LUS is technically feasible in a resource‐limited setting. This approach could help in making safer decisions on mode of birth in limited‐resource settings. Linked article: This article is commented on by Oyelese pp. 1780–1781 in this issue. To view this article visit https://doi.org/10.1111/1471‐0528.17909. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective Methods Results Conclusions Adhesions between the uterus, bladder and anterior abdominal wall are associated with clinical sequelae, including chronic pelvic pain and dyspareunia, and can also yield complications during surgery. The transvaginal sonographic (TVS) sliding bladder sign is a minimally invasive diagnostic tool to evaluate the presence of vesicouterine adhesions. This study aimed to determine the predictive value and intra‐ and interobserver variation of the TVS sliding bladder sign in the assessment of vesicouterine adhesions.This was a prospective observational double‐blind diagnostic accuracy study conducted at the Amsterdam University Medical Center. Patients scheduled for gynecological laparoscopic surgery for a benign disorder between January 2020 and December 2022 were included consecutively. All patients underwent preoperative TVS, including a dynamic sliding bladder sign examination in our outpatient clinic. Videoclips of the TVS scans were stored for offline assessment and used as an index test. The recordings of both TVS and laparoscopy were evaluated for diagnostic characteristics of vesicouterine adhesions by independent assessors, who were blinded to the clinical situation in addition to the laparoscopic findings when assessing recordings of TVS and vice versa. The presence of adhesions on laparoscopy was used as the reference standard. The positive predictive value (PPV), negative predictive value (NPV), specificity and sensitivity of the sliding bladder sign were calculated. In addition, inter‐ and intraobserver variability of the sliding bladder sign on TVS were assessed.Of 116 included women, 57 had a negative sliding bladder sign on TVS, while on laparoscopy, 51 women had mild and 28 had severe vesicouterine adhesions. A negative sliding bladder sign had a PPV of 94.7% (95% CI, 88.9–100%) for the presence of any vesicouterine adhesions, and a positive sliding bladder sign had a specificity of 91.9% (95% CI, 83.1–100%). For severe adhesions, the negative sliding bladder sign had a sensitivity of 89.3% (95% CI, 77.8–100%) and a positive sliding bladder sign had a NPV of 94.9% (95% CI, 89.3–100%). When using Cohen's kappa coefficient, inter‐ and intraobserver agreement between assessors was good.Sliding bladder sign evaluation using TVS is a reliable diagnostic tool for the prediction of vesicouterine adhesions on laparoscopy. A negative sliding bladder sign indicates the presence of vesicouterine adhesions, while a positive sliding bladder sign makes the presence of severe adhesions unlikely. Establishing vesicouterine adhesions by TVS may optimize preoperative planning, and can be used for future studies to evaluate the relationship between symptomatology and vesicouterine adhesions and, subsequently, the effect of adhesion‐prevention interventions. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

ABSTRACT A standardized methodology for the ultrasound evaluation of the pelvic sidewall has not been proposed to date. Herein, a collaborative group of gynecologists and gynecological oncologists with extensive ultrasound experience presents a systematic methodology for the ultrasonographic evaluation of structures within the pelvic sidewall. Five categories of anatomical structures are described (muscles, vessels, lymph nodes, nerves and ureters). A step‐by‐step transvaginal ultrasound (or, when this is not feasible, transrectal ultrasound) approach is outlined for the evaluation of each anatomical landmark within these categories. Accurate assessment of the pelvic sidewall using a standardized approach improves the detection and diagnosis of non‐gynecological pathologies that may mimic gynecological tumors, reducing the risk of unnecessary and even harmful intervention. Furthermore, it plays an important role in completing the staging of malignant gynecological conditions. Transvaginal or transrectal ultrasound therefore represents a viable alternative to magnetic resonance imaging in the preoperative evaluation of lesions affecting the pelvic sidewall, if performed by an expert sonographer. A series of videoclips showing normal and abnormal findings within each respective category illustrates how establishing a universally applicable approach for evaluating this crucial region will be helpful for assessing both benign and malignant conditions affecting the pelvic sidewall. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Background: The increasing incidence of endometrial cancer (EC) has highlighted the need for improved early detection methods. This study aimed to develop and validate a novel DNA methylation classifier, EMPap, for EC detection using cervical scrapings. Methods: EMPap incorporated the methylation status of BHLHE22 and CDO1, along with age and body mass index (BMI), into a logistic regression model to calculate the endometrial cancer methylation (EM) score for identifying EC in cervical scrapings. We enrolled 1297 patients with highly suspected EC, including 196 confirmed EC cases, and assessed the EMPap performance in detecting EC. Results: EMPap demonstrated robust diagnostic accuracy, with an area under the curve of 0.93, sensitivity of 90.3%, and specificity of 89.3%. It effectively detected EC across various disease stages, grades, and histological subtypes, and consistently performed well across patient demographics and symptoms. EMPap correctly identified 87.5% of the type II ECs and 53.8% of premalignant lesions. Notably, compared with transvaginal ultrasonography (TVS) in patients with postmenopausal bleeding, EMPap exhibited superior sensitivity (100% vs. 82.0%) and specificity (85.2% vs. 38.5%). In asymptomatic postmenopausal women, EMPap maintained high sensitivity (89.5%) and negative predictive value (NPV) (98.3%). Conclusions: This study demonstrated the potential of EMPap as an effective tool for EC detection. Despite the limited sample size, EMPap showed promise for identifying type II EC and detecting over 50% of premalignant lesions. As a DNA methylation classifier, EMPap can reduce unnecessary uterine interventions and improve diagnosis and outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Imaging fibroid vascularity may predict fibroid growth and aid to determine most appropriate therapy. Microvascular (MV) flow imaging is relatively new and is able to detect slow flow in small vessels. Data on feasibility, reproducibility, and reliability of MV‐flow imaging in fibroids is lacking. The purpose of our study was to determine the reproducibility of MV‐flow imaging and to explore this technique for clinical practice for assessing blood flow in fibroids. Material and Methods: Thirty patients with one or multiple fibroids (diameter 1.5–12.0 cm) were prospectively included. Transvaginal ultrasound scanning was performed in B‐mode, 2D MV‐Flow™, 2D and 3D power Doppler mode (HERA W10, Samsung) by two experienced gynecologists at a tertiary care clinic from February to December 2021. The primary outcome was intra‐ and interobserver agreement of the vascular index (VI) and color score (CS). The following parameters: '2D MV‐flow VI', '3DPD VI', '2D MV‐flow CS' and '2DPD CS' were measured offline in the center, pseudocapsule, and entire fibroid. Secondary offline outcomes for exploring 2D MV‐flow for clinical practice, included (1) ability to discern vascular structures, (2) assessing the degree of vascularity via CS and calculating a VI, and (3) determining penetration depth of the ultrasound signal in both power Doppler and MV‐flow imaging. Results: All scans of the 30 included patients were of sufficient quality to analyze. Inter‐ and intra‐observer correlations of all studied parameters were good to excellent, both for 2D MV‐flow and 2D power Doppler (intercorrelation coefficient 0.992–0.996). Using 2D MV‐flow different vascular structures were visible in detail, in contrary to using 2D and 3D power Doppler. In significantly more fibroids central flow could be visualized using 2D MV‐flow (63%) than with 2D power Doppler (13%, p = 0.001). Finally, penetration of the ultrasound signal was deeper using 2D MV‐flow (3.92 cm) than with 2D power Doppler (2.95 cm, p = 0.001). Conclusions: Using 2D MV‐flow imaging for determining vascularity is highly reproducible. It has potential added value for clinical practice as it depicts detailed vascular structures and the degree of vascularity, especially in the center of the fibroid. [ABSTRACT FROM AUTHOR]

Arcuate uterus does not impact the success of infertility treatments, but there is no consensus on whether it influences perinatal outcomes. The objective of the present study was to investigate whether minor congenital uterine anomalies such as an arcuate uterus contribute to perinatal complications. This was a retrospective cohort study at a single institution. The study included 1097 deliveries after 22 weeks of gestation. Transvaginal ultrasound, with three‐dimensional functionality, assessed uterine morphology based on American Society for Reproductive Medicine criteria. We compared maternal backgrounds and perinatal complications between arcuate uterus and normal uterus groups. Statistical analyses, including multivariate analysis, aimed to identify independent risk factors. A total of 69 patients (7.5%) with diagnosed arcuate uterus were included. Maternal background factors showed no significant differences between groups. In perinatal complications, an arcuate uterus was associated with a significantly higher incidence of preterm delivery (13% versus 4.7%, P = 0.01), preterm premature rupture of membranes (7.2% versus 1.6%, P = 0.01), fetal growth restriction (FGR; 16% versus 6.7%, P = 0.01), and abnormal placental cord insertion (33% versus 7.6%, P < 0.01). After multivariate analysis, arcuate uterus emerged as an independent risk factor for preterm delivery (adjusted odds ratio [aOR], 4.0 [95% confidence interval (CI), 1.6–9.9], P < 0.01), FGR (aOR, 2.6 [95% CI, 1.2–5.6], P = 0.02), and abnormal placental cord insertion (aOR, 6.0 [95% CI, 3.4–10.6], P < 0.01). Arcuate uterus stands as an independent risk factor for preterm delivery, FGR, and abnormal placental cord insertion. The findings emphasize the importance of recognizing even minor uterine morphological abnormalities in assessing and managing perinatal complications. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion Registration at Clinical Trials To examine whether cervical ripening with a double balloon device for 6 h is as effective as 12 h in patients with a cervical length ≥ 30 mm measured on transvaginal ultrasound before induction of labor, and to determine whether patients with a long cervix need to have the balloon placed for a longer time.This is a secondary analysis of data from a randomized controlled trial that compared maternal and neonatal outcomes between women undergoing cervical ripening with a double balloon device for 6 h (study group) versus 12 h (control group). In this secondary analysis, we included only patients who had cervical length ≥ 30 mm measured on transvaginal ultrasound on admission. Our primary outcome was a Bishop score change after removal of the device. Secondary outcomes included insertion to delivery interval, mode of delivery, and oxytocin infusion duration.Sixty‐seven women met the inclusion criteria and were included in the analysis: 33 in the 6‐h group and 34 in the 12‐h group. Maternal characteristics were similar between both groups. Bishop score difference between the preinsertion and the postremoval scores were similar in the two groups (2.67 ± 1.8 vs. 2.53 ± 1.69, P = 0.76), while insertion to delivery time was 10 h shorter in the 6‐h group (20.95 vs. 31.21, P = 0.02; mean difference, −10.26 [95% CI, −19.0 to −1.51]). The other secondary outcomes remained similar in both groups.In women undergoing induction of labor who have a cervical length ≥ 30 mm measured on admission transvaginal ultrasound, removing a double balloon device after 6 h achieved similar Bishop score changes as removal after 12 h, but significantly reduced the time to delivery.https://classic.clinicaltrials.gov/ct2/show/NCT03045939. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion To detect an abnormal intra‐amniotic structure around the internal cervical os using transvaginal sonography at 18–21+6 weeks of gestation.In this cohort study, during a 12‐month period from July 2022 to June 2023, 395 transvaginal scans were performed for second‐trimester cervical‐length screening in singleton pregnancies at 18–21+6 weeks of gestation. Nine abnormal intra‐amniotic structures (AIAS), 87 low‐lying placentas (LLP, second‐trimester placenta previa or placental margin within 2 cm from internal cervical os), and 299 controls (not LLP and no abnormal finding around internal cervical os) were diagnosed. Sonographic features of AIAS and delivery outcomes in the three groups were compared.Sonographic features of nine AIAS cases were: two single bands, one single broad band, one multiple bands, one single tubular, and one multiple tubulars. Blood flow was noted in seven cases. Seven AIAS had disappeared by 26 weeks, one was resolved at 34 weeks, and one (vasa previa and parachute placenta) remained until delivery. Incidences of emergency cesarean section, abnormal placenta and umbilical cord, and abnormal deliveries in AIAS were significantly higher than those in LLP and control groups (P = 0.031). Blood losses during delivery in AIAS and LLP groups were significantly greater than in the control group (P = 0.004), but there was no significant difference in blood loss between AIAS and LLP groups.The incidence of AIAS around the internal cervical os in the second trimester was 2.28% (9/395 fetuses). Mid‐second‐trimester transvaginal sonographic screening for the detection of AIAS around the internal cervical os including vasa previa may be essential to reduce perinatal morbidity. [ABSTRACT FROM AUTHOR]

Background Objectives Search Strategy Selection Criteria Data Collection and Analysis Main Results and Conclusions Prostaglandins (PGs) have emerged as key drugs in second trimester medical abortion (STMA) and are currently a cornerstone in obstetric practice. Nevertheless, the application of PGs, integral to labor and abortion procedures, is not risk‐free, and has been associated with several complications, particularly maternal fever and uterine rupture (UR).The main outcome of the present systematic review was to assess the safety of PGs use in STMA, particularly in scarred uterus (SC).The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guideline. We performed a comprehensive systematic review by searching multiple databases, including MEDLINE, EMBASE, Global Health, The Cochrane Library, Health Technology Assessment Database, and the research registers of Web of Science during the years 1990–2022.Only articles regarding cases of UR occurred after the use of PGs for STMA were included in the article. We excluded papers regarding UR during first trimester abortion induction of labor or pregnancy or unrelated to PGs use for STMA. Risk of bias was assessed employing a modified version of the “Newcastle‐Ottawa Scale” (NOS).A total of 178 studies were initially identified as potentially meeting the criteria for inclusion in the review. After full text evaluation, 110 other articles were excluded and 67 studies that suited the inclusion criteria were included. A total of 19 of the included studies were judged to have a high risk of bias. Given the heterogeneous nature of the findings, we opted for a narrative synthesis of the results.PGs appear to be an effective pharmacologic tool for STMA; however, their use is not entirely risk‐free. STMA requires well‐equipped obstetric centers with skilled clinicians and surgeons prepared for emergencies. Ultrasonographic scans should be routinely performed during STMA management, since a UR can also be silent during the induction of labor. Intrapartum transabdominal, transperineal, and transvaginal ultrasound may have the diagnostic potential to early recognize this obstetric emergency, to facilitate rapid medical and surgical treatment, improving the outcome. [ABSTRACT FROM AUTHOR]

Introduction: Cesarean scar ectopic pregnancy (CSEP) is a rare gynecological disorder that occurs at a rate of approximately 0.05% of pregnancies and less than 0.2% of cesarean scars. The ultimate goal in the management of CSEP cases is to remove pregnancy and reduce morbidity while preserving fertility. This case report highlights the successful application of a conservative laparoscopic approach in managing a 14‐week viable CSEP. Case Presentation: A 35‐year‐old multiparous woman (G8P5A2L5) with five previous cesarean sections and five normal healthy children presented to the clinic with a viable CSEP of 14 weeks of gestation as revealed by abdominal and transvaginal ultrasound examination. The decision for a conservative laparoscopic approach was made in light of the patient's desire to preserve fertility. Intervention and outcome: The laparoscopic procedure included the following steps: extensive dissection of adhesions between the bladder and the uterus; identification of the ectopic pregnancy at the level of the lower segment; extraction of the product of conception in an endobag; and suturing of the lower segment defect. The successful execution of these steps resulted in the removal of the ectopic pregnancy while addressing associated structural concerns. This approach allowed for mitigating morbidity and, importantly, preserving the patient's fertility. Conclusion: This case highlights the importance of a conservative laparoscopic approach for CSEP in the second trimester. Imaging techniques play a pivotal role in accurate diagnosis, with minimally invasive technologies offering effective solutions. Individualized, patient‐centered approaches are necessary to prioritize clinical outcomes and patient preferences. [ABSTRACT FROM AUTHOR]

A 27‐year‐old nulliparous woman presented with a feeling of fullness in the lower abdomen and abdominal pain. A left ovarian tumor, uterus didelphys, left renal agenesis, and left vaginal atresia were observed on imaging. The ovarian tumor was presumed to have caused the abdominal pain, and an abdominal left adnexectomy was performed. After 3 months, she reported severe lower abdominal pain during menstruation. Transvaginal ultrasonography revealed uterine enlargement. After 17 days, the patient presented with abdominal pain and fever. She was diagnosed with peritonitis due to infection and left uterine hematometra. Because she did not improve with antibiotic treatment, left laparoscopic hysterectomy was performed. Subsequently, she did not experience the lower abdominal pain. Appropriate diagnosis and treatment based on the morphology of the reproductive tract and symptoms must be considered in patients with Herlyn–Werner–Wunderlich syndrome. Treatment must permit the outflow of menstrual blood. [ABSTRACT FROM AUTHOR]

Introduction: Preterm delivery (PTD) is the leading cause of death in children under 5 years of age. Cervical shortening detected by ultrasound can be used to predict PTD, but prediction is not perfect, and complementary diagnostic markers are needed. Recently, specific plasma microribonucleic acid (miRNAs) detected in early second trimester were shown to be associated with spontaneous PTD in high‐risk women with a singleton pregnancy. The aim of this study was to explore to what extent these miRNAs are associated with spontaneous PTD and cervical length in a general population. Material and Methods: This study is a nested case–control study within the CERVIX study. The CERVIX study evaluated the ability of cervical length screening with transvaginal ultrasound to identify women at risk of PTD. In the present study, women who delivered spontaneously <34 weeks (n = 61) were compared with a control group of women who delivered at full term (39 + 0 to 40 + 6 gestational weeks, n = 205). Archived serum samples were analyzed with RT‐qPCR for miRNA expression levels of let‐7a‐5p, miR‐150‐5p, miR‐15b‐5p, miR‐185‐5p, miR‐191‐5p, miR‐19b‐3p, miR‐23a‐3p, miR‐374a‐5p, and miR‐93‐5p. The mean relative expression was compared between the groups. Sub‐analyses were performed for women delivering <32, <30, and <28 weeks vs the full‐term group. Results: The analyzed miRNAs were not significantly differentially expressed in women delivering <34 weeks compared to those delivering at full term. MiR‐191‐5p and miR‐93‐5p were significantly overexpressed in women who delivered <32 weeks, and further increase in fold change was observed with decreasing gestational age at delivery. The level of miR‐15b‐5p was significantly higher in women delivering at <30 weeks compared to those delivering at full term. Conclusions: Our study shows that overexpression of miR‐93‐5p, miR‐15b‐5p, and miR‐191‐5p in serum at early gestation is associated with spontaneous PTD in a general population. Further research is needed to evaluate the potential of these miRNAs as future biomarkers for spontaneous PTD, as well as their pathophysiological role in spontaneous PTD. [ABSTRACT FROM AUTHOR]

Objective: This study aims to construct and evaluate a model to predict spontaneous vaginal delivery (SVD) failure in term nulliparous women based on machine learning algorithms. Methods: In this retrospective observational study, data on nulliparous women without contraindications for vaginal delivery with a singleton pregnancy ≥37 weeks and before the onset of labor from September 2020 to September 2021 were divided into a training set and a temporal validation set. Transperineal ultrasound was performed to collect angle of progression, head–perineum distance, subpubic arch angle, and their levator hiatal dimensions. The cervical length was measured via transvaginal ultrasound. The delivery methods were later recorded. Through LASSO regression analysis, indicators that can affect SVD failure were selected. Seven common machine learning algorithms were selected for model training, and the optimal algorithm was selected based on the area under the curve (AUC) to evaluate the effectiveness of the validation model. Results: Four indicators related to SVD failure were identified through LASSO regression screening: angle of progression, cervical length, subpubic arch angle, and estimated fetal weight. The Gaussian NB algorithm was found to yield the highest AUC (0.82, 95% confidence interval [CI] 0.65–0.98) during model training, and hence it was chosen for verification with the temporal validation set, in which an AUC of 0.79 (95% CI 0.64–0.95) was obtained with accuracy, sensitivity, and specificity rates of 80.9%, 72.7%, and 75.0%, respectively. Conclusion: The Gaussian NB model showed good predictive effect, proving its potential as a clinical reference for predicting SVD failure of term nulliparous women before actual delivery. Synopsis: The Gaussian NB model proves its potential as a clinical reference for predicting SVD failure of nulliparous women without contraindications for SVD before delivery. [ABSTRACT FROM AUTHOR]

Osseous metaplasia of the endometrium is a rare entity in which there is presence of mature or immature bone tissue in the endometrium. It is a rare disorder that usually leads to secondary infertility and is frequently associated with recurrent miscarriages and can be rarely asymptomatic. We present the case of a patient with endometrial ossification associated with secondary infertility. The patient presented with excessive vaginal discharge and was undergoing evaluation for secondary infertility. Transvaginal sonography showed a hyperechoic elongated lesion in the endometrium suggestive of endometrial calcification with posterior acoustic shadowing. Diagnostic hysteroscopy was done and the endometrial cavity showed multiple white‐colored, solid, fan‐shaped structures and bony spicules all over the endometrium, which were removed with a hysteroscopic grasper and sent for histopathological examination (HPE). The HPE confirmed the presence of bony trabeculae along with secretory endometrial glands. There have only been a few cases of endometrial osseous metaplasia reported in India and it is usually an overlooked cause of infertility. Although rare, we should consider this as a probable cause of secondary infertility when the characteristic ultrasound features are visualized and that hysteroscopic resection is the gold standard treatment. Synopsis: We present a case report of osseous metaplasia of the endometrium; the patient presented with secondary infertility and successful diagnosis and resection were done by hysteroscopy. [ABSTRACT FROM AUTHOR]

Introduction: Contrast‐enhanced computed tomography (CECT) is an emergent diagnostic imaging modality to identify the bleeding site and survey the abdominal cavity. The diagnostic utility of CECT for ectopic pregnancy (EP) has not been well‐investigated. The objective of this study was to evaluate the characteristics of CECT findings in patients with EP and extract specific findings that could contribute to the identification of implantation sites. Method: We conducted a retrospective study, reviewing suspected EP cases between April 2015 and March 2018 in our hospital. Clinical symptoms, blood test results, transvaginal sonography findings, and surgical and pathologic findings from the medical records were assessed. CECT images were evaluated by a certified radiologist and gynecologist retrospectively in consensus. The following were selected as positive findings for specific determination of the ectopic implantation site: the ectopic gestational sac, lateralization of the hemoperitoneum around the adnexa on either side, and extravascular leakage of the contrast agent outside the uterine cavity. Results: CECT was performed in 41 women with an EP. The ectopic implantation site was detectable on CECT in 90.2% (37/41), whereas it was noted in 70.0% (32/41) on transvaginal ultrasonography (TVS). Of nine patients with an EP with an undetectable implantation site on TVS, six were positive for the specific determination of the ectopic implantation site on CECT. Conclusion: CECT has the potential to predict ectopic implantation sites with high‐level sensitivity. As CECT is an urgent diagnostic imaging tool to be used in an emergent setting, it may be a good option for EP diagnosis when the availability of magnetic resonance imaging is limited. Synopsis: Contrast‐enhanced computed tomography has the potential to predict ectopic implantation sites and is a useful imaging tool in emergency situations. [ABSTRACT FROM AUTHOR]

The article discusses the use of transvaginal ultrasound (TVUS) for diagnosing endometriosis. It suggests that a simplified protocol focusing on specific anatomical structures can provide an efficient and accessible method for initial assessment. The authors argue for wider availability of TVUS in community imaging facilities to reduce diagnostic delay and improve quality of life for those with endometriosis. They also emphasize the importance of early diagnosis and propose incorporating endometriosis assessment into routine gynecological ultrasound examinations. However, they caution that a negative scan result does not rule out the possibility of endometriosis and further investigations may be needed. [Extracted from the article]

This article discusses the accuracy of ultrasound in detecting adenomyosis, a uterine disease characterized by the presence of ectopic endometrium and stroma in the myometrium. The study found that ultrasound performed poorly in detecting adenomyosis, especially when fibroids were present. The sensitivity of ultrasound was compared to magnetic resonance imaging (MRI), which was found to be more accurate in diagnosing adenomyosis. The authors suggest that access to MRI should be improved to ensure appropriate management of adenomyosis. [Extracted from the article]

Key Clinical Message: Ovarian hyperthecosis (OH) is a benign pathology, less common in premenopause. Literature is poor on its ultrasound (US) characteristics. We suggest that a heterogeneous ovary at US, with a central vascularisation and follicles to the periphery, with or without hyperandrogenism, should lead to consider OH in the hands of experts. [ABSTRACT FROM AUTHOR]

Early diagnosis and appropriate management of Cesarean scar pregnancy (CSP) are crucial to prevent severe complications, such as uterine rupture, severe hemorrhage and placenta accreta spectrum disorders. In this article, we provide a step‐by‐step tutorial for the standardized sonographic evaluation of CSP in the first trimester. Practical steps for performing a standardized transvaginal ultrasound examination to diagnose CSP are outlined, focusing on criteria and techniques essential for accurate identification and classification. Key sonographic markers, including gestational sac location, cardiac activity, placental implantation and myometrial thickness, are detailed. The evaluation process is presented according to assessment of the uterine scar, differential diagnosis, detailed CSP evaluation and CSP classification. This step‐by‐step tutorial emphasizes the importance of scanning in two planes (sagittal and transverse), utilizing color or power Doppler and differentiating CSP from other low‐lying pregnancies. The CSP classification is described in detail and is based on the location of the largest part of the gestational sac relative to the uterine cavity and serosal lines. This descriptive classification is recommended for clinical use to stimulate uniform description and evaluation. Such a standardized sonographic evaluation of CSP in the first trimester is essential for early diagnosis and management, helping to prevent life‐threatening complications and to preserve fertility. Training sonographers in detailed evaluation techniques and promoting awareness of CSP are critical. The structured approach to CSP diagnosis presented herein is supported by a free e‐learning course available online. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the association of sonographic features and clinical symptoms of adenomyosis. Methods: This was a prospective observational study. Only reproductive age women who underwent standardized transvaginal ultrasound examination were included. The diagnosis of adenomyosis was based on sonographic features proposed by Morphological Uterus Sonographic Assessment (MUSA) group. Pictorial blood loss assessment chart (PBAC) and numerical rating scale (NRS) were respectively used for the evaluation of menstrual bleeding and pain. Results: Fifty‐three women were recruited. Adenomyosis group consisted of 33 (62.3%) representative cases, whereas control group consisted of 20 (37.7%). Women with adenomyosis experienced significantly heavier menstrual bleeding (p = 0.008) and more painful menstrual periods (p = 0.003). Significant positive correlation between the number of sonographic adenomyosis features and both PBAC (r = 0.613, p < 0.001) and NRS scores (r = 0.402, p = 0.022) was found. PBAC score was significantly higher if either fan‐shaped shadowing (r = 0.548, p = 0.001), interrupted junctional zone (JZ) (r = 0.548, p = 0.001) or globular uterus (r = 0.445, p = 0.011) was detected. Interrupted JZ (r = 0.440, p = 0.012) was associated with higher NRS score. Significant positive correlation between PBAC score and adenomyosis spread in uterine layers (r = 0.495, p = 0.004) was established. Conclusion: Certain sonographic features of adenomyosis and assessment of its involvement in uterine layers may predict the severity of adenomyosis symptoms. [ABSTRACT FROM AUTHOR]

Introduction Key Findings Discussion Vasa previa is a complication of pregnancy, which affects approximately 1:1200 pregnancies, and when undiagnosed prenatally, it can be associated with significant perinatal mortality. This condition is thought to be a sporadic entity without known genetic or familial associations and thus considered to carry a negligible recurrence risk.We present a case of a 42‐year‐old gravida 3 para 2 diagnosed on transvaginal ultrasound with a vasa previa at 34 weeks associated with vaginal bleeding, which required an urgent caesarean in a prior spontaneous pregnancy. In the current pregnancy conceived with in vitro fertilisation, she was again diagnosed with a vasa previa at 30 weeks’ gestation at transvaginal ultrasound. She ultimately delivered at 37 weeks’ gestation via an uncomplicated repeat caesarean.Patients with vasa previa in one pregnancy may be at risk for recurrence in subsequent pregnancy and thus should be screened in future pregnancies. Further research should be done to explore and identify any risk factors for recurrence of vasa previa. [ABSTRACT FROM AUTHOR]

The incidence of unilateral tubal twin pregnancy is 1/20,000–1/250,000 with about 100 reported cases. Four of the six cases that were medically managed were successful. A 24‐year‐old female presented to the emergency department (ED) with vaginal bleeding and abdominal cramping. She was hemodynamically stable without signs of an acute abdomen. Laboratory evaluation revealed she was pregnant with a serum beta‐human chorionic gonadotropin (b‐hCG) of 798 mIU/mL. Transvaginal ultrasound (TVUS) revealed a single left tubal pregnancy with a yolk sac. The patient elected medical management with body surface area (BSA)–based intramuscular (IM) methotrexate (MTX). On Day 4, the patient returned to the ED; her b‐hCG was 727 mIU/mL. TVUS revealed twin left tubal pregnancies with yolk sacs and fetal poles without cardiac activity. The patient elected to continue medical management with a second dose of BSA‐based IM MTX. On Day 6, the patient returned to the ED with abdominal and rectal pain. She was hemodynamically stable without signs of an acute abdomen. Her b‐hCG was 533 mIU/mL. TVUS showed persistent twin left tubal pregnancies—one at 5 weeks gestational age and the other at 6 weeks gestational age—without evidence of rupture. The patient continued serial b‐hCGs. Thirty‐one days after the first dose of MTX, her b‐hCG was < 1 mIU/mL. TVUS showed resolution of tubal pregnancies. The patient consented to the publication of this case report. This case documents the successful treatment of spontaneous, unilateral tubal twin pregnancies with two‐step dosing of IM MTX. [ABSTRACT FROM AUTHOR]

Gestational trophoblastic neoplasia (GTN) with spinal metastasis is rare with few documented cases worldwide. Few studies have explored chemotherapy combined with radiotherapy in the treatment of such cases. However, because of its rarity, there is still no standardized treatment regimen. A 34‐year‐old Gravida 1 Para 0 (0010) was diagnosed with GTN with metastasis to the lumbosacral spine, resulting in conus medullaris syndrome with lumbar radiculopathy. She presented with a 14‐month history of amenorrhea, left lower extremity pain, and urinary and bowel retention. On examination, there was a 10.0 × 7.0 cm lumbosacral mass and atrophy of the left lower extremity. Transvaginal ultrasound showed a cul de sac mass, and diluted β‐human chorionic gonadotropin (β‐hCG) titer was markedly elevated at more than 1000 000 mIU/mL. Magnetic resonance imaging (MRI) of the lumbosacral spine showed an ill‐defined sacral mass measuring 13.3 × 11.5 × 6.3 cm with spinal canal, bone, muscle, and nerve root involvement. She was treated with 10 cycles of EMACO and palliative radiotherapy with 10 sessions of 30 Gy of external beam radiation therapy directed toward the lumbosacral mass. Repeat MRI showed a decrease in size of the mass to 6.6 × 8.2 × 4.1 cm with concurrent decrease in β‐hCG to 1.30 mIU/ml, and resolution of leg pain and urinary and bowel symptoms. She was declared to be in remission 3 months after the last cycle of EMACO. [ABSTRACT FROM AUTHOR]

Objective: To evaluate ureteral involvement using transvaginal sonography (TVS) regarding the distortion of the course of the ureters caused by deep endometriosis (DE), which can facilitate predicting the need for ureterolysis during surgery, even in the absence of ureteral stenosis or dilatation. Methods: This is a single‐center, observational, retrospective pilot study of 88 consecutive patients who later underwent surgery for DE that used ultrasound preoperative diagnosis of ureteral medial deviation of one or both ureters between January 2019 and January 2022. At TVS, the course of the ureter was considered medialized if, in longitudinal and transversal section, any distance was detectable between the ureter and the cervix at the point where the ureter crosses the uterine artery. The primary end point was to determine sensitivity, specificity, and positive and negative predictive values of "ureteral medial deviation" diagnosed using TVS, in order to predict the need for ureterolysis. Results: Our series included 88 women with a median age of 39 (interquartile range 33–43) years. Ureteral medialization showed a relatively low false‐positive rate (10.9%), with a specificity of 89.1% (95% confidence interval [CI] 81.4%–96.7%) and a sensitivity of 86.6% (95% CI 80.3%–92.9%), along with a high positive predictive value of 93.3% (95% CI 88.4%–98.1%), and a lower negative predictive value of 79.1% (95% CI 69.8%–88.5%), respectively. Conclusions: This study introduced a new ultrasound sign with a high degree of accuracy to predict ureterolysis and this may have positive implications in the management and surgical planning of patients with ureteral endometriosis. Synopsis: Evaluation of ureteral involvement regarding the distortion of the course of the ureters by deep endometriosis, which can facilitate predicting the need for ureterolysis. [ABSTRACT FROM AUTHOR]

Introduction: There is a gap in knowledge regarding development of endometriosis and adenomyosis lesions visible at transvaginal ultrasound. The objectives were to evaluate if women with symptoms suggestive of endometriosis or adenomyosis but normal ultrasound examination develop endometriosis or adenomyosis lesions visible at ultrasound over time and if alterations of symptoms over time are associated with ultrasound findings at follow‐up. Material and Methods: This was a prospective cohort study of 100 symptomatic women with normal initial ultrasound examination during 2014–2017 who underwent follow‐up ultrasound examination in 2022. Symptoms suggestive of endometriosis were assessed using visual analog scale at both examinations and minimal clinically important difference of 10 mm was considered as a significant alteration. An examiner with expertise in advanced ultrasound examination of endometriosis performed transvaginal ultrasound examinations in accordance with the consensus protocol by the International Deep Endometriosis Analysis group. Results: At follow‐up ultrasound examination of 100 women, 13 (13% [95% CI 7.1–21.2]) had visible endometriosis or adenomyosis lesions, 8 (8% [95% CI 3.5–15.2]) had endometriosis lesions, and 6 (6% [95% CI 2.2–12.6]) had adenomyosis. At follow‐up, women with endometriosis or adenomyosis lesions reported lower intensity of dysmenorrhea and chronic pelvic pain compared to women without lesions (48 mm [IQR 16–79] vs. 73 mm [IQR 46–85] and 45 mm [IQR 26–57] vs. 57 mm [IQR 36–75], p = 0.087 and p = 0.026, respectively). None of the women with endometriosis or adenomyosis lesions reported increased intensity of dysmenorrhea at follow‐up, compared to 32/86 women (37%) without lesions (p = 0.008). Increased intensity of chronic pelvic pain tended to be less common in women with lesions compared to those without (3/13 [23%] vs. 35/86 [41%], p = 0.223). Conclusions: Our findings suggest that in symptomatic women, endometriosis and adenomyosis lesions visible at ultrasound may develop over time. However, majority of women remain having normal ultrasound examinations despite symptoms. Exacerbation of dysmenorrhea or chronic pelvic pain during follow‐up was not associated with the development of endometriosis or adenomyosis lesions visible at ultrasound, suggesting that even women with less severe symptoms might benefit from a follow‐up ultrasound when indicated. [ABSTRACT FROM AUTHOR]

Objective: To assess the diagnostic performance of transvaginal sonography (TVS) for the preoperative evaluation of lymph‐node metastasis in gynecological cancer. Methods: This was a systematic review and meta‐analysis of studies published between January 1990 and May 2023 evaluating the role of ultrasound in detecting pelvic lymph‐node metastasis (index test) in gynecological cancer, using histopathological analysis as the reference standard. The quality of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies‐2 tool. Pooled sensitivity, specificity and diagnostic odds ratio were estimated. Results: The literature search identified 2638 citations. Eight studies reporting on a total of 967 women were included. The mean prevalence of pelvic lymph‐node metastasis was 24.2% (range, 14.0–65.6%). The risk of bias was low for most domains assessed. Pooled sensitivity, specificity and diagnostic odds ratio of TVS were 41% (95% CI, 26–58%), 98% (95% CI, 93–99%) and 32 (95% CI, 14–72), respectively. High heterogeneity was found between studies for both sensitivity and specificity. Conclusion: TVS showed a high pooled specificity for the detection of pelvic lymph‐node metastasis in gynecological cancer, but pooled sensitivity was low. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

This article explores the development and prenatal imaging of the corpus callosum (CC), a crucial structure in the brain that facilitates communication between the two hemispheres. Prenatal imaging techniques like ultrasound and MRI have made it possible to study the CC's development earlier than before. The article also discusses the various abnormalities that can be observed in the CC during prenatal imaging and the challenges in accurately describing and classifying these abnormalities. The authors propose a simplified classification system based on well-defined criteria to improve the diagnosis and prognosis of CC anomalies. [Extracted from the article]

As scientific projects and labs benefit from increasingly interdisciplinary expertise, students and trainees find themselves navigating a myriad of academic spaces, each with its own workplace culture and demographics. A clear example is the interdisciplinary field of optics and biological microscopy which bridges biology, physics and engineering. While Biology PhDs are now >50% women, men in physics and engineering fields still significantly outnumber women, resulting in an imbalance of gender representation among microscopists and other 'tool innovators' in the interdisciplinary field of biological microscopy and biomedical optics. In addition to the cultural and cognitive whiplash that results from disparate representation between fields such as Biology, Engineering, and Physics, indifference from institutional leaders to implement equity‐focused initiatives further contributes to cultures of exclusion, rather than belonging, for women. Here we elaborate on the motivation, structure, and outcomes of building a specific affinity‐based bootcamp as an intervention to create an inclusive, welcoming learning environment for women in optics. Considering the presence of nonbinary, trans and other gender minoritised scientists, we recognise that women are not the only gender group underrepresented in biological microscopy and biomedical optics; still, we focus our attention on women in this specific intervention to improve gender parity in biological microscopy and biomedical optics. We hope that these strategies exemplify concrete paths forward for increasing belonging in interdisciplinary fields, a key step towards improving and diversifying graduate education. [ABSTRACT FROM AUTHOR]

Objective: To investigate the value of the sonographic identification of deep infiltrating endometriosis (DIE) in women presenting with complaints suggestive of DIE. Sonography findings were correlated with subsequent surgical exploration, and histologic verification. Methods: A retrospective observational case series was investigated to document the ability of the use of sonography to accurately detect the presence of deep infiltrating endometriosis. The clinical observations were performed consistent with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations for observational studies. Recognizing the real‐world office setting for this may introduce the importance of the practical clinical aspects of diagnostic procedures in general. Results: Three‐dimensional transvaginal sonography was able to accurately identify deep invasive endometriosis in 92% of the 100 women subjectively complaining of the associated symptoms of endometriosis, who underwent sonography, surgical exploration, and pathologic analysis. Additional sonographic evidence of pelvic pathology was found during the course of this investigation, perhaps complementing other means for diagnosing endometriosis. Conclusion: Three‐dimensional transvaginal sonography is a diagnostic tool that can effectively identify deep infiltrating endometriosis, which may otherwise go undetected and untreated. These findings should encourage the use of sonography for the detection of this subtype of endometriosis. Synopsis: A series of cases is described of sonographically detected deep infiltrating endometriosis with three‐dimensional transvaginal sonography, which were all surgically explored and histologically examined. [ABSTRACT FROM AUTHOR]

Problem: Achieving pregnancy through in vitro fertilization (IVF) remains a challenge, with less than one‐third of women succeeding. There is a pressing need for reliable predictive tools to assess the likelihood of post‐IVF pregnancy. While some serum inflammatory biomarkers have been investigated for their predictive potential, substantial knowledge gaps persist. This study examined the utility of different inflammatory markers in predicting IVF outcomes. Method of Study: Inflammatory markers including the white blood cell count, neutrophil‐to‐lymphocyte ratio (NLR), platelet count, mean platelet volume, platelet distribution width, platelet‐to‐lymphocyte ratio (PLR), C‐reactive protein (CRP), erythrocyte sedimentation rate, and vitamin D3 were assessed. Study outcomes were chemical pregnancy (positive serum beta‐human chorionic gonadotropin 2 weeks post‐embryo transfer), clinical pregnancy (detection of pregnancy sac via transvaginal ultrasonography), and viable pregnancy (detection of fetal heart rate). Univariate and multivariate logistic regression analyses were conducted, with multivariate analysis incorporating age, body mass index, infertility duration, type, and etiology, as well as all studied serum inflammatory markers, embryo count, stage, quality, and endometrial thickness. Results: Lower NLR (p < 0.001, odds ratio [OR] = 0.372 [0.247–0.559]) and CRP (p = 0.035, odds ratio = 0.956 [0.916–0.997]) predicted chemical pregnancy in univariate analysis, with NLR maintaining significance in multivariate analysis (p = 0.022, OR = 0.319 [0.120–0.848]). Lower NLR (p < 0.001, OR = 0.309 [0.198–0.482]) and PLR (p = 0.013, OR = 0.994 [0.990–0.999]) predicted clinical pregnancy, with NLR surviving multivariate analysis (p = 0.005, OR = 0.217 [0.075–0.626]). Lower NLR (p < 0.001, OR = 0.320 [0.198–0.516]) also predicted viable pregnancy, maintaining statistical significance in multivariate analysis (p = 0.002, OR = 0.177 [0.058–0.541]). Other studied inflammatory markers did not predict IVF outcomes. Conclusions: NLR emerged as a robust independent predictor of pregnancy attainment after IVF. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the safety of current guidelines on methotrexate (MTX) administration in women with pregnancy of unknown location (PUL) who are considered to have a high risk of underlying ectopic pregnancy (EP), and to investigate whether implementation of these guidelines would result in inadvertent exposure to MTX of viable intrauterine pregnancies (IUPs). Methods: This was a retrospective observational study of consecutive clinically stable women who were classified with PUL at the early pregnancy unit of Nepean Hospital, Sydney, Australia, between 2007 and 2021. PUL was defined as a positive pregnancy test in the absence of signs of IUP or EP on transvaginal ultrasound. Patients with a PUL that behaved biochemically like an EP, but for which the location of pregnancy was not confirmed on ultrasound, were eligible for MTX to minimize the risk of subsequent tubal rupture. Criteria discussed in the guidelines of the American College of Obstetricians and Gynecologists (ACOG), American Society for Reproductive Medicine (ASRM), Royal College of Obstetricians and Gynaecologists (RCOG) and National Institute for Health and Care Excellence (NICE) were applied to the PUL database. The number of patients eligible to receive MTX and the number with an underlying viable IUP who would be inadvertently prescribed MTX were calculated. Results: A total of 816 women with PUL were reviewed, of whom 724 had complete data and were included in the final analysis. Six patients had persistent PUL and the remaining 718 had a diagnosis of viable IUP, non‐viable IUP, EP or failed PUL. According to the ACOG, ASRM, RCOG and NICE guidelines, the rate of MTX administration among patients with PUL would have been 2.76%, 4.56%, 0.41% and 35.36%, respectively. However, no persistent PUL would have received MTX according to the ACOG, ASRM and RCOG protocols (the NICE protocol identified patients with persistent PUL with a sensitivity of 100%), and the majority of MTX treatments were unnecessary because those patients were later classified as having non‐viable IUP or failed PUL. Application of ACOG and ASRM guidance could result theoretically in inadvertent MTX administration to women with an underlying viable IUP at a rate of 4.1/1000 (3/724). Conclusions: Current guidelines used to predict high risk of EP in the PUL population lead to inadvertent MTX administration to women with an underlying viable IUP. These guidelines should be used wisely to ensure that no wanted pregnancy is exposed to MTX. Women with PUL should be monitored carefully, and MTX should be used judiciously when the location of pregnancy is yet to be confirmed. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objective: To describe the sonomorphological changes and appearance of deep endometriosis (DE) affecting the nervous tissue of the sacral plexus (SP). Methods: This was a retrospective study of symptomatic patients who underwent radical resection of histologically confirmed DE affecting the SP and who had undergone preoperative transvaginal sonography (TVS) between 2019 and 2023. Lesions were described based on the terms and definitions of the International Deep Endometriosis Analysis (IDEA), International Ovarian Tumor Analysis (IOTA) and Morphological Uterus Sonographic Assessment (MUSA) groups. A diagnosis of DE affecting the SP on TVS was made when the sonographic criteria of DE were visualized in conjunction with fibers of the SP and the presence of related symptoms corresponding to sacral radiculopathy. Clinical symptoms, ultrasound features and histological confirmation were analyzed for each patient included. Results: Twenty‐seven patients with DE infiltrating the SP were identified in two contributing tertiary referral centers. Median age was 37 (range, 29–45) years and all patients were symptomatic and presented one or more of the following neurological symptoms: dysesthesia in the ipsilateral lower extremity (n = 17); paresthesia in the ipsilateral lower extremity (n = 10); chronic pelvic pain radiating in the ipsilateral lower extremity (n = 9); chronic pain radiating in the pudendal region (n = 8); and motor weakness in the ipsilateral lower extremities (n = 3). All DE lesions affecting the SP were purely solid tumors in the posterior parametrium in direct contact with, or infiltrating, the S1, S2, S3 and/or S4 roots of the SP. The median of the largest diameter recorded for each of the DE nodules was 35 (range, 18–50) mm. Echogenicity was non‐uniform in 23 (85%) of the DE nodules, with all but one of these nodules containing hyperechogenic areas. The shape of the lesions was irregular in 24 (89%) cases. Only one lesion exhibited a lobulated form, with all other irregular lesions showing a spiculated appearance. An acoustic shadow was produced in 20 (74%) of the nodules, all of which were internal. On color or power Doppler examination, 21 (78%) of the nodules showed no signal (color score of 1). The remaining six (22%) lesions showed a minimal color content (color score of 2). According to pattern recognition, most DE nodules were purely solid, non‐uniform, hypoechogenic nodules containing hyperechogenic areas, with internal shadows and irregular spiculated contours, and were poorly vascularized on color/power Doppler examination. Conclusion: The ultrasound finding of a parametrial, unilateral, solid, non‐uniform, hypoechogenic nodule with hyperechogenic areas and possible internal shadowing, as well as irregular spiculated contours, demonstrating poor vascularization on Doppler examination in proximity to or involving the structures of the SP, indicates DE affecting the SP. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

The article in the journal "Ultrasound in Obstetrics & Gynecology" by Pozzoni et al. discusses the diagnosis and outcome of Type‐III vasa previa (VP), emphasizing the need for universal screening between the first and second trimester due to the challenges in diagnosing this condition. The authors highlight the importance of ultrasonographic assessment, dynamic TVS with color Doppler imaging, and 3D ultrasound evaluation in detecting Type‐III VP, as traditional methods may lead to missed diagnoses. The case study presented in the article underscores the complexities of diagnosing Type‐III VP and suggests a multi‐step evaluation approach for suspected cases. [Extracted from the article]

The article discusses the importance of transvaginal ultrasound imaging in grading intracervical hypervascularity to predict maternal outcomes in cases of placenta accreta spectrum (PAS). The topography of PAS and lower bladder involvement play a crucial role in determining the surgical strategy for PAS. Utilizing three-dimensional ultrasound rendering techniques can provide valuable information on the complexity of PAS surgery, with intracervical hypervascularity grading helping to identify warning signs for PAS during screening. Different grades of intracervical hypervascularity correlate with the success of one-step conservative surgery, with Grade 3 indicating the lowest chance of success and a higher risk of unexpected bleeding during surgery. [Extracted from the article]

This article discusses the assessment of interindividual follicular size variation at ovulation in natural-cycle frozen embryo transfer (FET). The study found that there is considerable variation in follicular size at ovulation, ranging from 12 to 26 mm. The authors suggest that relying solely on parameters such as follicle size, estradiol (E2) level, and cycle day may be unreliable for establishing monitoring intervals and predicting ovulation in the first natural-cycle FET. They propose that measuring progesterone (P4) levels could be used to confirm ovulation and plan embryo transfer, reducing the costs of hormonal monitoring. [Extracted from the article]

This article discusses a rare type of uterine ectopic pregnancy called intramural pregnancy (IMP). IMP occurs when a pregnancy is implanted within the uterine corpus, above the internal cervical os, separate from the interstitial section of the Fallopian tube. The article presents a case of twin IMP after embryo transfer (ET), which was successfully treated laparoscopically. The patient later conceived again and delivered a healthy baby. The article emphasizes the importance of early and precise diagnosis of IMP, as it can be managed if diagnosed in the first trimester. [Extracted from the article]

The presence of calculi inside the uterine cavity is an uncommon finding, with few cases described in the literature. Here, we present a clinical case of a 30‐year‐old patient with uterine lithiasis. The patient presented with 3 months of evolution, characterized by abdominal pain in the hypogastrium, with a report of transvaginal ultrasound of hematometra with suggestive images of endometrial polyps. For this reason, she was scheduled for hysteroscopy, where three lesions of hard consistency were found, with the largest 1.5 cm. Currently, due to the few cases of uterine lithiasis described, there is no explanation of how the stones are formed in the uterine cavity. The age of the patient in this case report and the absence of predisposing factors for uterine calcifications reported in the literature is striking, which leads us to propose a hypothesis of the origin of uterine lithiasis, which is related to the history of cesarean section and the presence of hematometra, such hematic retention could have predisposed to the development of calculi in this patient. Uterine lithiasis is an extremely rare entity with few published cases; therefore, further studies are necessary. Synopsis: We present an extremely rare case of uterine lithiasis, a disease for which only three cases have been previously reported in the literature. [ABSTRACT FROM AUTHOR]

Objective: To predict spontaneous preterm birth (sPTB) (labor before 37 weeks of pregnancy) in low‐risk singleton pregnancies during the second trimester, using ultrasound markers: uterocervical angle (UCA) and cervical length (CL). Methods: In a prospective observational cohort study, we followed primigravid women with singleton pregnancies without known risk factors for sPTB from 16+0–23+6 weeks of pregnancy until birth. Transvaginal ultrasonography on admission revealed the UCA and CL, and maternal history was obtained from submitted patient profiles. Logistic regression models disclosed significant predictive variables, and receiver operating curves (ROCs) demonstrated optimal cut‐offs and test accuracy indices. Predictive functions of variables were compared using positive and negative likelihood ratios. Results: In a sample of 357 participants, 41 (11.5%) experienced sPTB. UCA and CL were significantly associated with sPTB when adjusting for other variables (adjusted odds ratio: UCA 1.05, 95% confidence interval [CI] 1.02–1.07 and CL 0.82, 95% CI 0.75–0.90). Optimal cut‐offs were estimated to be 106° and 33 mm for UCA and CL, respectively. We devised the novel index UCA/CL with an area under the ROC of 0.781 (95% CI 0.734–0.823), cut‐off = 3.09°/mm, and improved likelihood ratios (positive: 3.18, 2.47, and 4.22; negative: 0.63, 0.52, and 0.51 for UCA, CL, and UCA/CL, respectively). Conclusion: The second‐trimester UCA/CL was found to be a promising index to predict sPTB in low‐risk singleton pregnancies. Further multicenter studies may generalize this conclusion to other gestational ages or risk groups and make it more comprehensive by considering other risk factors. Synopsis: Using the uterocervical angle divided by cervical length, a novel index that may predict spontaneous preterm birth could be developed. [ABSTRACT FROM AUTHOR]

Introduction: Studies that use standardized ultrasonographic criteria to diagnose adenomyosis in subfertile women are needed. These would improve the understanding of the disease burden and enable further studies on its impact on fertility and assisted reproductive treatment (ART) outcome. The aim of this study was to determine the prevalence of different features of adenomyosis in women scheduled for their first ART, diagnosed at two (2D) and three‐dimensional (3D) transvaginal ultrasonography (TVUS) using the revised Morphological Uterus Sonographic Assessment (MUSA) group definitions. Material and methods: This was a prospective, observational cross‐sectional study of subfertile women aged 25 to ≤39 years, that were referred to a university hospital for their first ART between December 2018 and May 2021. Of 1224 eligible women, 1160 women fulfilled the inclusion criteria and consented to participate in the study. All women underwent a systematic 2D and 3D TVUS examination. The primary outcome was the presence of direct and indirect features of adenomyosis, as proposed by the MUSA group. Secondary outcomes were to describe the ultrasonographic characteristics of the different features, as well as any difference in the diagnostics at 2D or 3D TVUS and any association with clinical characteristics such as endometriosis. Results: At least one direct or indirect feature of adenomyosis was observed in 272 (23.4%, 95% confidence interval [CI] 21.0–25.9) women. Direct features that are pathognomonic for the disease were observed in 111 (9.6%, 95% CI, 7.9–11.3) women. Direct features were visible only at 3D TVUS in 56 (4.8%, 95% CI 3.6–6.1) women, that is, 56/111 (50.5%) of women with at least one direct adenomyosis feature. Direct features were more common in women with endometriosis (OR 2.8, 95% CI 1.8–4.3). Conclusions: We found than one in 10 women scheduled for ART had direct features of adenomyosis at ultrasound examination. The present study suggests that the use of 3D TVUS is an important complement to 2D in the diagnostics of adenomyosis. Our results may further improve the counseling of women scheduled for ART and enables future studies on the impact of different features of adenomyosis on subfertility, ART results and obstetric outcomes. [ABSTRACT FROM AUTHOR]

Objective: To evaluate longitudinal changes in cervical length (CL) and mean cervical shear wave elastography (CSWE) score in women with a singleton or twin pregnancy who undergo spontaneous preterm birth (sPTB) compared with those who deliver at term. Methods: This was a prospective longitudinal study of unselected women with a singleton or twin pregnancy attending a dedicated research clinic for screening for sPTB at four timepoints during pregnancy: 11 + 0 to 15 + 6 weeks, 16 + 0 to 20 + 6 weeks, 21 + 0 to 24 + 6 weeks and 28 + 0 to 32 + 6 weeks. At each visit, a transvaginal ultrasound scan was conducted to measure the CL and the CSWE scores in six regions of interest (ROI) (inner, middle and external parts of anterior and posterior cervical lips). The mean CSWE score from the six ROIs was calculated for analysis. Log10 transformation was applied to data to produce a Gaussian distribution prior to statistical analysis. A multilevel mixed‐effects analysis was performed to compare longitudinally CL and CSWE between the sPTB and term‐delivery groups. Results: The final cohort consisted of 1264 women, including 1143 singleton pregnancies, of which 57 (5.0%) were complicated by sPTB, and 121 twin pregnancies, of which 33 (27.3%) were complicated by sPTB. Compared to those who delivered at term, women with sPTB had a lower CL across gestation when controlling for history of cervical surgery, number of fetuses, gestational age (GA) at cervical assessment and the interaction between GA at cervical assessment and sPTB (P < 0.001). Specifically, CL in the sPTB group was significantly lower at 21 + 0 to 24 + 6 weeks (P = 0.039) and 28 + 0 to 32 + 6 weeks (P < 0.001). Twin pregnancies had significantly greater CL throughout pregnancy compared with singleton pregnancies (regression coefficient, 0.01864; P < 0.001). After adjusting for maternal age, weight, height, body mass index and GA at cervical assessment, CSWE score in the sPTB group was significantly lower compared with that in the term‐delivery group across gestation (P = 0.013). However, on analysis of individual visits, CSWE score in the sPTB group was significantly lower than that in the term‐delivery group only at 11 + 0 to 15 + 6 weeks (P = 0.036). There was no difference in CSWE score between singleton and twin pregnancies throughout gestation (regression coefficient, –0.00128; P = 0.937). Conclusions: Women with sPTB have a shorter and softer cervix across gestation compared with those who deliver at term. A shorter cervix in the sPTB group is observed from the late second trimester onwards, while lower cervical stiffness in the sPTB group is observed primarily in the first trimester. CL is significantly lower in singleton pregnancies compared with twin pregnancies, while cervical stiffness does not differ between the two. Our findings indicate that the cervix tends to undergo a softening process prior to shortening in sPTB cases. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objective: Intraoperative hemorrhage and peripartum hysterectomy are the main complications in patients presenting with a low‐lying placenta or placenta previa undergoing repeat Cesarean delivery (CD). Patients with a high probability of placenta accreta spectrum (PAS) at birth also have a higher risk of intraoperative urologic injury. The aim of this study was to evaluate the ultrasound signs and intraoperative features associated with these injuries. Methods: This was a retrospective case–control study of consecutive singleton pregnancies included in a prospective cohort of patients with a history of at least one prior CD and diagnosed prenatally with an anterior low‐lying placenta or placenta previa at 32–36 weeks' gestation. All patients underwent investigational preoperative transabdominal and transvaginal ultrasound examination within 48 h prior to delivery. Ultrasound anomalies of uterine contour and uteroplacental vascularity, and gross anomalies of the lower uterine segment (LUS) and surrounding pelvic tissue at delivery, were recorded using a standardized protocol, which included evaluation of the extent of uterine contour anomalies. The diagnosis of PAS was established when one or more placental lobules could not be separated digitally from the uterine wall at delivery or during the gross examination of the hysterectomy or partial myometrial resection specimens, and was confirmed by histopathology. Data were compared between cases complicated by intraoperative bladder injury and controls from the same cohort matched at a 1:3 ratio by parity and the number of prior CDs using conditional logistic regression. Results: There were 16 (9.4%) patients with an intraoperative bladder injury in a cohort of 170 managed by the same multidisciplinary team during the study period. There were no patients diagnosed with ureteric or bladder trigone damage. There were 14 (87.5%) patients with a bladder injury that had histopathologic evidence of PAS at birth, including 11 (68.8%) cases described on microscopic examination as placenta increta and three (18.8%) as placenta creta. There was a significant (P = 0.03) difference between cases and controls in the distribution of intraoperative LUS vascularity, whereby the higher the number of enlarged vessels, the higher the odds of bladder injury. Multivariable regression analysis revealed that both gestational age at delivery and LUS remodeling on transabdominal ultrasound were associated with bladder injury. A higher gestational age was associated with a lower risk of injury. A higher LUS remodeling grade on transabdominal ultrasound was associated with an increased risk of bladder injury. Patients with Grade‐3 remodeling (involving > 50% of the LUS) had 9‐times higher odds of a bladder injury compared to patients with Grade‐1 remodeling (involving < 30% of the LUS). Conclusions: Preoperative ultrasound examination is useful in the evaluation of the risk of intraoperative bladder injury in patients with a history of prior CD presenting with a low‐lying placenta or placenta previa. The larger the remodeling of the LUS on transabdominal ultrasound, the higher the risk of adverse urologic events. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objective: To describe the ultrasonographic appearance of the post‐ablative endometrium to improve knowledge of its sonographic findings. Methods: This was an Institutional Review Board approved prospective study of patients who underwent second‐generation endometrial ablation from 2016 to 2019 at a single health system. Patients had postoperative transvaginal ultrasounds at 2, 6, and 12 months. Ultrasound reports were analyzed for endometrial thickness, description of the endometrium and myometrium, presence of uterine fibroids, and uterine size. Statistical tests for repeated measures were utilized. Results: There were 68 patients with the average age of 42 (SD 6) years and a BMI of 33 (SD 8). Preoperatively the average endometrial thickness was 10 mm, uterine length was 9.7 cm, and 38.2% had leiomyoma. The average endometrial thickness decreased at each ultrasound: 8.4 mm (SD 3.4), 7.2 mm (SD 3.0), and 5.8 mm (SD 2.5) at 2, 6, and 12 months, respectively. When comparing endometrial thickness postoperatively there was a significant difference at 2 and 12 months (P =.041), and 6 and 12 months (P =.031). There was no change during the postoperative period in the presence of leiomyoma, hyperechoic endometrium, hypoechoic endometrium, heterogeneous endometrium, and cystic endometrium on the ultrasounds. Conclusion: After ablation with a second‐generation device, the endometrial thickness on ultrasound decreases with time following surgery. Additional studies correlating these findings to clinical outcomes would be useful. [ABSTRACT FROM AUTHOR]

Objective: To confirm the identity and assess the prevalence and evolution of the fluid‐filled interhemispheric midline structure, thought to be the cavum veli interpositi (CVI), in fetuses at 11–14 weeks' gestation. Methods: This was a retrospective study of first‐trimester ultrasound scans performed at a single center over 3 months. Inclusion criteria were singleton pregnancies at 11–14 weeks' gestation with known neonatal outcome. Five experts reviewed the images. Mixed‐effects logistic regression and generalized estimating equations (GEE) were conducted to analyze the associations between the presence of the structure and variables including ultrasound approach (transabdominal vs transvaginal), maternal body mass index (BMI), gestational age, fetal crown–rump length (CRL) and biparietal diameter (BPD). Second‐trimester ultrasound scans of the fetal central nervous system at 18–24 weeks' gestation were evaluated for the persistence of the CVI in fetuses in which the structure was observed in the first trimester. Results: Of the 223 cases reviewed, 104 were included, among which the CVI was observed in 25 (24%) cases. There was no statistically significant difference in CVI visualization between transabdominal and transvaginal ultrasound examinations. GEE showed significant associations between the presence of the fetal structure and CRL (odds ratio (OR) per 10‐unit increase, 1.32; P < 0.0001) and BPD (OR per 10‐unit increase, 1.88; P = 0.0011). Maternal BMI and gestational age showed no significant effect on the presence of the CVI. At second‐trimester follow‐up of the 25 fetuses in which the CVI was observed initially, 44% still showed a CVI, 32% exhibited a cavum vergae, 4% had both structures and 20% had neither. Conclusions: Based on its anatomical location and, in some fetuses, its visualization as a distinct entity from the third ventricle, the identity of the interhemispheric midline structure in the suprathalamic region of the fetal brain between 11–14 weeks' gestation was confirmed as the CVI. The CVI and/or cavum vergae persisted into the second trimester in 80% of fetuses identified initially as having a CVI. Its presence is not linked to pathology, offering reassurance to practitioners and parents. © 2023 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objectives: Our objectives were: (1) to assess the visualization rate of the choroid bar in a consecutive series of 306 first‐trimester scans; (2) to verify, in this cohort of fetuses, the normality of the posterior fossa later in pregnancy; and (3) to confirm the non‐visualization of the choroid bar in a retrospective series of fetuses with posterior fossa malformations. Methods: This study included a prospective and a retrospective series. The former comprised 306 fetuses undergoing routine obstetric ultrasound at our unit in both the first and second trimesters over a 6‐month period, while the latter comprised 12 cases of posterior fossa malformations. In the prospective study, the presence of the choroid bar, which is defined as a visually continuous, homogeneously hyperechogenic, thick structure bridging the cisterna magna from side to side, was evaluated at the end of the first‐trimester nuchal translucency scan. In the retrospective study, previously acquired three‐dimensional volume datasets were processed in order to assess whether the choroid bar could be visualized in cases of open spinal dysraphisms and vermian cystic anomalies. In the prospective study, confirmation of a normal posterior fossa was based on the sonographic features of this anatomical region at the time of the second‐trimester anomaly scan at 19–21 weeks' gestation, while, in the retrospective study, it was based on autopsy results, when available, or further direct imaging of the defect later in pregnancy. Results: In the prospective study, the choroid bar could be visualized in all 306 fetuses, on transabdominal ultrasound in 287 (93.8%) cases and on transvaginal ultrasound in 19 (6.2%) cases. The choroid bar was displayed with a ventral/dorsal approach in 67 (21.9%) cases, with a lateral approach in 56 (18.3%) cases and with both in 183 (59.8%) cases. All 306 cases were confirmed to have a sonographically normal posterior fossa at 19–21 weeks. On the other hand, in the retrospective study, it was not possible to visualize the choroid bar in any of the fetuses with posterior fossa malformations. Conclusions: We have described a new sign, the choroid bar, consistent with a normal posterior fossa at 12–14 weeks' gestation. The choroid bar provides the option of screening for major abnormalities of the posterior fossa, since its absence raises suspicion of both open spinal dysraphisms and posterior fossa cystic malformations. At the same time, it is easy to visualize, as it can be seen with all lines of insonation. © 2023 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objectives: To assess the ability of the International Endometrial Tumor Analysis (IETA)‐1 polynomial regression model to estimate the risk of endometrial cancer (EC) and other intracavitary uterine pathology in women without abnormal uterine bleeding. Methods: This was a retrospective study, in which we validated the IETA‐1 model on the IETA‐3 study cohort (n = 1745). The IETA‐3 study is a prospective observational multicenter study. It includes women without vaginal bleeding who underwent a standardized transvaginal ultrasound examination in one of seven ultrasound centers between January 2011 and December 2018. The ultrasonography was performed either as part of a routine gynecological examination, during follow‐up of non‐endometrial pathology, in the work‐up before fertility treatment or before treatment for uterine prolapse or ovarian pathology. Ultrasonographic findings were described using IETA terminology and were compared with histology, or with results of clinical and ultrasound follow‐up of at least 1 year if endometrial sampling was not performed. The IETA‐1 model, which was created using data from patients with abnormal uterine bleeding, predicts four histological outcomes: (1) EC or endometrial intraepithelial neoplasia (EIN); (2) endometrial polyp or intracavitary myoma; (3) proliferative or secretory endometrium, endometritis, or endometrial hyperplasia without atypia; and (4) endometrial atrophy. The predictors in the model are age, body mass index and seven ultrasound variables (visibility of the endometrium, endometrial thickness, color score, cysts in the endometrium, non‐uniform echogenicity of the endometrium, presence of a bright edge, presence of a single dominant vessel). We analyzed the discriminative ability of the model (area under the receiver‐operating‐characteristics curve (AUC); polytomous discrimination index (PDI)) and evaluated calibration of its risk estimates (observed/expected ratio). Results: The median age of the women in the IETA‐3 cohort was 51 (range, 20–85) years and 51% (887/1745) of the women were postmenopausal. Histology showed EC or EIN in 29 (2%) women, endometrial polyps or intracavitary myomas in 1094 (63%), proliferative or secretory endometrium, endometritis, or hyperplasia without atypia in 144 (8%) and endometrial atrophy in 265 (15%) women. The endometrial sample had insufficient material in five (0.3%) cases. In 208 (12%) women who did not undergo endometrial sampling but were followed up for at least 1 year without clinical or ultrasound signs of endometrial malignancy, the outcome was classified as benign. The IETA‐1 model had an AUC of 0.81 (95% CI, 0.73–0.89, n = 1745) for discrimination between malignant (EC or EIN) and benign endometrium, and the observed/expected ratio for EC or EIN was 0.51 (95% CI, 0.32–0.82). The model was able to categorize the four histological outcomes with considerable accuracy: the PDI of the model was 0.68 (95% CI, 0.62–0.73) (n = 1532). The IETA‐1 model discriminated very well between endometrial atrophy and all other intracavitary uterine conditions, with an AUC of 0.96 (95% CI, 0.95–0.98). Including only patients in whom the endometrium was measurable (n = 1689), the model's AUC was 0.83 (95% CI, 0.75–0.91), compared with 0.62 (95% CI, 0.52–0.73) when using endometrial thickness alone to predict malignancy (difference in AUC, 0.21; 95% CI, 0.08–0.32). In postmenopausal women with measurable endometrial thickness (n = 848), the IETA‐1 model gave an AUC of 0.81 (95% CI, 0.71–0.91), while endometrial thickness alone gave an AUC of 0.70 (95% CI, 0.60–0.81) (difference in AUC, 0.11; 95% CI, 0.01–0.20). Conclusion: The IETA‐1 model discriminates well between benign and malignant conditions in the uterine cavity in patients without abnormal bleeding, but it overestimates the risk of malignancy. It also discriminates well between the four histological outcome categories. © 2023 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objectives: To explore clinical value of miRNA‐18a, miRNA‐130a, and miRNA‐92a combined with transvaginal color Doppler ultrasound (TVCDS) in the diagnosis of cervical cancer (CC). Methods: One hundred patients with pathologically confirmed CC (CC group), 100 patients with cervical epithelial neoplasia (disease group), and 100 patients with benign uterine lesions (control group) were selected. TVCDS was performed, and the levels of serum miRNA‐18a, miRNA‐130a, and miRNA‐92a were detected. Results: The systolic blood velocity of the cancer group, the disease group, and the control group decreased sequentially, while the resistance index and pulsatility index increased sequentially. The serum miR‐18a, miR‐130a, miR‐92a, and expression levels of the patients' increased sequentially. Multivariate logistic regression analysis showed that age, high‐risk human papillomavirus (HR‐HPV) infection, menopause, blood flow RI, serum miRNA‐18a, miRNA‐92a, and miRNA‐130a were the influencing factors of CC. The receiver operating characteristic curve showed that the sensitivity, specificity, accuracy, and area under curve of transvaginal Doppler ultrasound in the diagnosis of CC were 86.43%, 88.01%, 84.32%, and 0.913; serum miR‐18a were, respectively, 76.56, 81.30, 80.36, and 0.839; serum miR‐130a were 77.88%, 76.97%, 78.32%, and 0.0.864; serum miR‐92a were 71.04%, 80.39%, 80.74%, and 0.894; 90.33%, 95.14%, 91.25%, and 0.947, the area under curve of the combined detection of the 3 was greater than that of the single detection. Conclusions: Serum miRNA combined with TVCDS has the advantages of it being noninvasive, and having high sensitivity and high specificity in the diagnosis of CC. Access the CME test here and search by article title. [ABSTRACT FROM AUTHOR]

The accurate assessment of wound healing post‐caesarean section, especially in twin pregnancies, remains a pivotal concern in obstetrics, given its implications for maternal health and recovery. Traditional methods, including conventional abdominal ultrasonography (CU), have been challenged by the advent of transvaginal ultrasonography (TU), offering potentially enhanced sensitivity and specificity. This meta‐analysis directly compares the efficacy of TU and CU in evaluating wound healing and scar formation, crucial for optimizing postoperative care. Results indicate that TU is associated with significantly better outcomes in wound healing, demonstrated by lower REEDA scores (SMD = −20.56, 95% CI: [−27.34.20, −13.77], p < 0.01), and in scar formation reduction, evidenced by lower Manchester Scar Scale scores (SMD = −25.18, 95% CI: [−29.98, −20.39], p < 0.01). These findings underscore the potential of integrating TU into routine post‐caesarean evaluation protocols to enhance care quality and patient recovery. [ABSTRACT FROM AUTHOR]

This article discusses the diagnosis of isthmocele, a uterine defect that occurs at the site of a previous cesarean section or other uterine surgeries. It affects up to 70% of women with a history of cesarean sections and can cause symptoms such as abnormal uterine bleeding and abdominal pain. Accurate diagnosis is important as isthmocele has been linked to complications in future pregnancies. Transvaginal ultrasonography is the primary diagnostic method, and the study suggests that performing the ultrasound during the secretive phase of the menstrual cycle provides clearer visualization of the isthmocele. Surgical correction can be done depending on the size of the defect. [Extracted from the article]

This article discusses the clinical application of intraoperative ultrasound for the management of placenta accreta spectrum (PAS) disorders. The study aimed to determine if intraoperative ultrasound, combined with preoperative and surgical findings, could provide evidence for conservative management with safe placental removal in suspected PAS cases. The researchers conducted a prospective study and evaluated nine suspected cases at three stages: preoperative, intraoperative, and postoperative. Intraoperative ultrasound images were found to be clearer than preoperative images, and the identification of a retroplacental myometrial layer was associated with complete placental separation. The authors conclude that intraoperative ultrasound can provide additional information for surgical staging and safe placental removal, but further studies are needed. [Extracted from the article]

Objectives: Ectopic pregnancy (EP) is a major high‐risk outcome following a pregnancy of unknown location (PUL) classification. Biochemical markers are used to triage PUL as high vs low risk to guide appropriate follow‐up. The M6 model is currently the best risk‐prediction model. We aimed to update the M6 model and evaluate whether performance can be improved by including clinical factors. Methods: This prospective cohort study recruited consecutive PUL between January 2015 and January 2017 at eight units (Phase 1), with two centers continuing recruitment between January 2017 and March 2021 (Phase 2). Serum samples were collected routinely and sent for β‐human chorionic gonadotropin (β‐hCG) and progesterone measurement. Clinical factors recorded were maternal age, pain score, bleeding score and history of EP. Based on transvaginal ultrasonography and/or biochemical confirmation during follow‐up, PUL were classified subsequently as failed PUL (FPUL), intrauterine pregnancy (IUP) or EP (including persistent PUL (PPUL)). The M6 models with (M6P) and without (M6NP) progesterone were refitted and extended with clinical factors. Model validation was performed using internal–external cross‐validation (IECV) (Phase 1) and temporal external validation (EV) (Phase 2). Missing values were handled using multiple imputation. Results: Overall, 5473 PUL were recruited over both phases. A total of 709 PUL were excluded because maternal age was < 16 years or initial β‐hCG was ≤ 25 IU/L, leaving 4764 (87%) PUL for analysis (2894 in Phase 1 and 1870 in Phase 2). For the refitted M6P model, the area under the receiver‐operating‐characteristics curve (AUC) for EP/PPUL vs IUP/FPUL was 0.89 for IECV and 0.84–0.88 for EV, with respective sensitivities of 94% and 92–93%. For the refitted M6NP model, the AUCs were 0.85 for IECV and 0.82–0.86 for EV, with respective sensitivities of 92% and 93–94%. Calibration performance was good overall, but with heterogeneity between centers. Net Benefit confirmed clinical utility. The change in AUC when M6P was extended to include maternal age, bleeding score and history of EP was between −0.02 and 0.01, depending on center and phase. The corresponding change in AUC when M6NP was extended was between −0.01 and 0.03. At the 5% threshold to define high risk of EP/PPUL, extending M6P altered sensitivity by −0.02 to −0.01, specificity by 0.03 to 0.04 and Net Benefit by −0.005 to 0.006. Extending M6NP altered sensitivity by −0.03 to −0.01, specificity by 0.05 to 0.07 and Net Benefit by −0.005 to 0.006. Conclusions: The updated M6 model offers accurate diagnostic performance, with excellent sensitivity for EP. Adding clinical factors to the model improved performance in some centers, especially when progesterone levels were not suitable or unavailable. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]